Limitations of epidemiology in understanding pathogenesis of cataracts.
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Case-Control Studies↗
Biomedical subjects
G J Johnson
Publications and source records attributed to G J Johnson.
[Value of anterior chamber lenses in developing countries. Results of a clinical study].
UNLABELLED: There are estimated to be 20 million people blinded by cataracts, 80-90% of whom live in rural areas of developing countries where expert surgical resources are scarce. The majority of all cataract operations are still intracapsular extractions (ICCE). Aphakic correction using spectacles is problematical in developing countries. This study was undertaken to evaluate the safety of multiflex open loop anterior chamber intraocular lenses (AC IOLs). METHODS: A total of 2000 people attending Lahan Eye Hospital, South-east Nepal, with bilateral cataract were randomly allocated to receive in their first eye either ICCE with AC IOL (AC IOL group) or ICCE with aphakic correction (control group). All operations were performed by two ophthalmologists using a standardized technology and 4.5 x operating loupe magnification. Functional and best corrected vision was recorded. The primary outcome measure was poor vision after surgery, which was defined as a visual acuity of less than 6/60 at 1 year follow-up (WHO definition for severe visual impairment and blindness). FINDINGS: The median time needed to perform ICCE was 4.1 min and to perform ICCE with AC IOL 6 min. Of all study patients 91% were examined after 1 year. Five percent of the AC IOL group and 5.4% of the control group had a functional visual acuity of less than 6/60. Causes of reduced vision in the AC IOL group versus the control group were: correctable refractive error (22 vs 29), uveitis/secondary glaucoma (13 vs 2), endophthalmitis (4 vs 7), pre-existing eye diseases (4 vs 5), retinal detachment (0 vs 4), and corneal decompensation (0 vs 1). Of the control group, 24 patients were found to be functionally blind in the operated eye (vision < 3/60) because they did not wear their aphakic spectacles. Normal vision (WHO definition: > or = 6/18) was achieved best corrected in 89.9% of the AC IOL group and 93.2% of the control group. Analysis of additional long-term follow-ups (2-5 years post-operatively) has not yet been completed. INTERPRETATION: This study provides evidence that in developing countries well-manufactured multiflex open loop AC IOLs can be implanted safely by experienced ophthalmologists after routine ICCE, avoiding the disadvantages of aphakic spectacle correction.
Anterior Chamber↗
Morphometric assessment of epidermal and mucous-biofilm changes caused by exposure of trout to chloramine-T or formalin treatment.
Juvenile rainbow trout were exposed to therapeutic concentrations of formalin or chloramine-T to assess the effects of these chemicals on the morphology of the piscine epidermis and its mucous coat. Repeated treatment, once weekly for 4 weeks, with either chemical did not affect the mucous coat of the epithelium or the degree of folding of the basal lamina. However, treated fish had increased numbers of highly dense vesicles within the apical portions of epithelial cells. The epidermal mucous cells of chloramine-T-treated fish were significantly smaller than in controls. This effect was not noted in formalin-treated fish. Treatment with either chemical resulted in a significantly thinned epidermis. It is concluded that although chloramine-T and formalin may continue to be useful in the aquaculture industry they cause potentially harmful alterations to fish skin.
Animals↗
Central corneal thickness and intraocular pressure in a Mongolian population.
OBJECTIVE: The purpose of the study was to quantify the variation of central corneal thickness (CCT) in an east Asian population and to examine its relationship to estimates of intraocular pressure (IOP) made with an applanation tonometer. DESIGN: The study design was a cross-sectional, population-based survey. PARTICIPANTS: One thousand two-hundred forty-two residents of Hövsgöl Province, Mongolia, 10 to 87 years of age participated. MAIN OUTCOME MEASURES: The CCT was measured using an optical pachymeter in all subjects. The IOP was measured using a, Goldmann-type applanation tonometer in subjects 40 years of age and older. RESULTS: There was a highly significant decrease in CCT with age: 5 microns/decade in men and 6 microns/decade in women (both, P < 0.0001). A highly significant positive correlation was identified between IOP and CCT. Linear regression analysis suggests that between the ages of 40 and 80 years, an increase in CCT of 10 microns is associated with an increase in IOP measurements of 0.18 mmHg in right eyes (95% confidence interval, 0.12-0.25) and 0.24 mmHg in left eyes (95% confidence interval, 0.17-0.31). The authors calculate that interindividual differences in CCT may produce a difference in measured IOP of between 2.3 and 3.1 mmHg. CONCLUSIONS: Variation in CCT is a significant source of variation in IOP measurements between individuals. The authors suggest that measurement of corneal thickness should be considered when assessing IOP as a risk factor for glaucoma in east Asians.
Adolescent↗
Is anterior chamber lens implantation after intracapsular cataract extraction safe in rural black patients in Africa? A pilot study in KwaZulu-Natal, South Africa.
PURPOSE: There are an estimated 16 million people blind from cataract world-wide. In many areas the routine operation is intracapsular cataract extraction (ICCE). The role of modern anterior chamber (AC) intraocular lenses (IOLs) is being explored, and they have been shown to be safe and successful in Asia. Are they equally safe in rural black African populations? METHODS: One hundred black patients aged 50 years and over who attended Edendale Hospital were enrolled in a pilot study of insertion of AC IOLs after ICCE. They were followed up for 6 months. RESULTS: With financial remuneration, the follow-up rate at 8 weeks increased from the usual 30% to 72%. At 6 months, 67% of eyes achieved a correlated visual acuity of 6/18 or better. Thirty per cent had persistent uveitis, 16% had peripheral anterior synechiae beyond the points of haptic contact, and 5% had an intraocular pressure greater than 21 mmHg. CONCLUSIONS: A randomised trial comparing ICCE with AC IOL and extracapsular cataract extraction with posterior chamber IOL is probably not justified at this time in this population. However, there may be wide variations in the reaction of the eyes of different African ethnic groups to IOLs. In view of the successful use of AC IOLs in Asian eyes, further pilot studies of AC IOLs may be warranted in other parts of Africa where ICCE is the routine procedure.
Black or African American↗
Randomised trial of 0.2% chlorhexidine gluconate and 2.5% natamycin for fungal keratitis in Bangladesh.
AIM: The management of suppurative keratitis due to filamentous fungi presents severe problems in tropical countries. The aim was to demonstrate the efficacy of chlorhexidine 0.2% drops as an inexpensive antimicrobial agent, which could be widely distributed for fungal keratitis. METHODS: Successive patients presenting to the Chittagong Eye Institute and Training Complex with corneal ulcers were admitted to the trial when fungal hyphae had been seen on microscopy. They were randomised to drop treatment with chlorhexidine gluconate 0.2% or the standard local treatment natamycin 2.5%. The diameters, depths, and other features of the ulcers were measured and photographed at regular intervals. The outcome measures were healing at 21 days and presence or absence of toxicity. If there was not a favourable response at 5 days, "treatment failure" was recorded and the treatment was changed to one or more of three options, which included econazole 1% in the latter part of the trial. RESULTS: 71 patients were recruited to the trial, of which 35 were randomised to chlorhexidine and 36 to natamycin. One allocated to natamycin grew bacteria and therefore was excluded from the analysis. None of the severe ulcers was fully healed at 21 days of treatment, but three of those allocated to chlorhexidine eventually healed in times up to 60 days. Of the nonsevere ulcers, 66.7% were healed at 21 days with chlorhexidine and 36.0% with natamycin, a relative efficacy (RE) of 1.85 (CL 1.01-3.39, p = 0.04). If those ulcers were excluded where fungi were seen in the scraping but did not grow on culture, the estimated efficacy ratio does not change but becomes less precise because of smaller numbers. Equal numbers of Aspergillus (22) and Fusarium (22) were grown. The Aspergillus were the most resistant to either primary treatment. CONCLUSIONS: Chlorhexidine may have potential as an inexpensive topical agent for fungal keratitis and warrants further assessment as a first line treatment in situations where microbiological facilities and a range of antifungal agents are not available.
Adolescent↗
Trachoma in The Gambia.
BACKGROUND: As part of the second National Survey of Blindness and Low Vision in the Gambia carried out in 1996, all survey participants were examined for signs of trachoma. The findings were compared with the results of the first survey in 1986, which used the same sampling strategy. METHODS: A multistage stratified cluster random sample, with proportional probability sampling, was obtained. Stratification included settlement size (less than 400 residents, and 400 and more residents). All subjects were examined for trachoma using the simplified WHO grading system. RESULTS: Of the sample of 14,110 people, 13,047 (92.5%) were examined. Active inflammatory trachoma (grade TF or TI) was found in 3.0% of all age groups and 5.9% of children aged 0-9 years old. Trichiasis was found in 3.3% and trachomatous corneal opacities in 0.9% of adults aged 30 and over. The prevalence of blinding trachomatous corneal opacities was 0.02%, compared with 0.10% 10 years previously. CONCLUSION: Compared with a previous national survey undertaken in 1986, prevalence of active trachoma has fallen by 54%. There has been an 80% relative reduction in blinding trachomatous corneal opacities over the 10 year period.
Adolescent↗
Reduction of trachoma in a sub-Saharan village in absence of a disease control programme.
BACKGROUND: Trachoma is a leading cause of blindness in the developing world and is most prevalent among people who live in poor rural communities in arid locations. METHODS: We analysed the results of surveys of trachoma prevalence in Marakissa, a rural village in The Gambia. These surveys were undertaken in 1959, by the Medical Research Council, and in 1987 and 1996 by the Gambian National Eye Care Programme. FINDINGS: During this 37-year period, the prevalence of active inflammatory trachoma among children aged 0-9 years fell from 65.7 cases per 100 children in 1959 to 2.4 cases per 100 children in 1996. The prevalence also fell dramatically among people of 10-19 years (52.5 to 1.4 per 100) and among people of 20 years and older (36.7 to 0 cases per 100). INTERPRETATION: The dramatic fall in disease occurrence was paralleled by improvements in sanitation, water supply, education, and access to health care in the village. Of particular importance is that the decline in trachoma occurred without any trachoma-specific intervention.
Adolescent↗
Randomised controlled trial of anterior-chamber intraocular lenses.
BACKGROUND: There are an estimated 16 million people blind in both eyes with cataracts. Most live in rural areas of developing countries where surgical resources are scarce. There is no consensus on the most appropriate type of intraocular lens in situations where high-volume low-cost surgery is required. This study was undertaken to evaluate the safety of multiflex open-loop anterior-chamber lenses (ACIOLs). METHODS: 2000 people attending Lahan Eye Hospital, southern Nepal, with bilateral cataracts reducing vision to 6/36 or less were randomly allocated to receive standard surgery--intracapsular extraction (ICCE) with aphakic correction--or ICCE with an ACIOL in their first operated eye. The primary outcome was a visual acuity of less than 6/60 in the operated eye at 1 year follow-up. Visual acuity was measured for 91% of the cohort at 1 year. The sample size was estimated to detect a doubling in poor visual outcome from an estimated rate of 4% in the standard surgery (control) group. FINDINGS: The median (range) time taken to do the surgery was 6.0 (3.0-17.2) min for the ACIOL group and 4.1 (2.4-10.3) min for the control group. 1 year after surgery, 5.0% of the ACIOL group and 5.4% of controls had functional vision less than 6/60 (OR 0.93 [0.60-1.43], p = 0.71). The causes of poor vision in the ACIOL and control groups were: correctable refractive error (22 and 29), uveitis/secondary glaucoma (13 and two), endophthalmitis (four and seven), pre-existing eye disease (four and five), retinal detachment (none and four), cystoid macular oedema (two and none), corneal ulcer (one and one), and corneal decompensation (none and one). INTERPRETATION: This study provides evidence that, in rural areas of developing countries, multiflex open-loop ACIOLs can be implanted safely by experienced ophthalmologists after routine ICCE, avoiding the disadvantages of aphakic spectacle correction. Further follow-up is planned.
Anterior Chamber↗
An epidemic of optic neuropathy in Tanzania: characterization of the visual disorder and associated peripheral neuropathy.
An epidemic of subacute bilateral visual failure has affected large numbers of teenagers and young adult Africans in coastal Tanzania since 1988. Previous work had indicated that many patients had sensory symptoms, but the nature of the neurological involvement was uncertain. The primary objective of this study was to characterize the accompanying neurological disorder. Furthermore, the nature of the visual loss was uncertain from previous reports as both retinopathy and optic neuropathy had been suggested. Full ophthalmic and neurological examinations were carried out at the Muhimbili University Hospital in Dar es Salaam. Nerve conduction studies, pattern electro-retinograms and cortical visually evoked responses and colour contrast sensitivity tests were carried out. Thirty eight young Africans and 12 controls were included in the study. The characteristic fundus picture was symmetrical temporal optic atrophy, and thinning of the caeco-central nerve fibre layer. Fluorescein angiography was normal. The electrophysiological and colour contrast sensitivity tests confirmed optic neuropathy in the majority of cases but primary retinal involvement was indicated in some. Neurological examination and nerve conduction measurements showed evidence of a peripheral neuropathy in 47% of the patients. The peripheral neuropathy is likely to have involved large fibres (from the nerve conduction studies) but the symptoms suggest small fibre loss also. 42% had developed hearing loss. Urinary thiocyanate levels were uniformly low. Serum was negative for antibodies to HTLV-1. DNA analysis from three cases was negative for three known mutations associated with Leber's hereditary optic atrophy (11778, 3460 and 14484). This entity, occurring predominantly in a young age group, does not correspond closely to other tropical neurological syndromes previously described from East Africa although it is clinically very similar to Strachan's syndrome (originally described in the Caribbean and more recently in prisoners of war) and also to an epidemic of optic and peripheral neuropathy that has recently occurred in Cuba. The aetiology has not yet been determined. A micronutrient deficiency is likely but has not been established.
Adolescent↗
Anterior chamber depth in Mongolians: variation with age, sex, and method of measurement.
PURPOSE: To document anterior chamber depth in a Mongolian population and quantify the variation in this parameter attributable to age, sex, and method of measurement. METHOD: Depth of the anterior chamber was measured by optical pachymetry in 1,242 subjects aged 10 to 87 years. Figures for "true" anterior chamber depth were calculated by subtracting central corneal thickness from the distance between the anterior corneal epithelium and anterior lens capsule. A-mode ultrasound was also used to measure the distance from anterior corneal epithelium to anterior lens capsule in 94% (942) of subjects aged 40 years and older. These ultrasound data were compared with measurements of the same distance obtained by optical pachymetry. RESULTS: Mean anterior chamber depth in women was more shallow than in men of all ages (ANOVA, P < .0001), although this difference varied according to age. Mean anterior chamber depth decreased with age and was most accurately represented by a cubic function of age. This change was maximal between the ages of 30 and 60 years and equaled 0.15 mm per decade in men and 0.21 mm per decade in women. Mean depth of the anterior chamber measured by ultrasound was significantly less than the equivalent optical measurement (difference of 0.14 mm in right eyes, P < .001). CONCLUSIONS: Mean anterior chamber depth in Mongolians decreases with age and is more shallow in women than in men. Ultrasound and optical methods of anterior chamber depth measurement yield significantly different results and are therefore not directly comparable.
Adolescent↗
Adaptation of a fluorocarbon-based non-aqueous fixation regime for the ultrastructural study of the teleost epithelial mucous coat.
Studies on the microanatomy of the mucus-rich biofilm surface of normal or damaged teleost skin tissue have been limited because conventional fixation regimes do not effectively retain mucus during tissue preparation. A non-aqueous fixation method, based on a technique devised to retain airway mucous for ultrastructural study, and consisting of the use of an inert perfluorocarbon solvent with osmium teroxide 1%, was successfully used to prepare skin tissues of healthy juvenile rainbow trout. The skin's mucous coat was examined by transmission electron microscopy and the results were compared with those obtained with tissues prepared by a conventional glutaraldehyde-based method. In samples fixed with glutaraldehyde, the cell-surface structures retained were limited to microridges and a poorly discernible glycocalyx layer. In contrast, those fixed by the non-aqueous method had a more clearly demonstrated glycocalyx layer, and a second fibrillar layer, resembling mucus, which was separated from the glycocalyx layer by an electron-lucent zone.
Animals↗
Nationwide prevalence study of hypertension and related non-communicable diseases in The Gambia.
The prevalence of hypertension, diabetes and obesity in The Gambia was assessed in a 1% population sample of 6048 adults over 15 years of age, 572 (9.5%) subjects were hypertensive according to WHO criteria (a diastolic blood pressure (DBP) of 95 mmHg or above and/or a systolic blood pressure (SBP) of 160 mmHg or above); 325 (5.4%) had a DBP of 95 mmHg or above, and 39 (2.3%) a DBP of 105 mmHg or above; 428 (7.1%) had a SBP of 160 mmHg or above. By less conservative criteria (a DBP of 90 mmHg or above and/or SBP of 140 mmHg or above), 24.2% of subjects were hypertensive. The prevalence of hypertension was similar in the major ethnic groups and in urban and rural communities. Age and obesity were risk factors for hypertension; female sex was an additional risk factor for diastolic hypertension. Several communities had a prevalence of diastolic hypertension double the national rate, and significant community clustering of diastolic hypertension (P < 0.01) was confirmed by Monte Carlo methods. Genetic and/or localized environmental factors (such as diet or Schistosoma haematobium infection), may be involved 140 (2.3%) subjects were obese. Obesity was associated with female sex, increasing age, urban environment, non-manual work and diastolic hypertension. Only 14 (0.3%) subjects were found to be diabetic. Hypertension appears to be very prevalent in The Gambia, with a substantial population at risk of developing target organ damage. Further studies to delineate this risk and appropriate interventions to reduce it are needed.
Adolescent↗
Trial of chlorhexidine gluconate for fungal corneal ulcers.
AIMS: Suppurative corneal ulcers due to filamentous fungi are a serious and intractable problem in many tropical developing countries. In vitro studies and a small pilot study have shown that chlorhexidine gluconate is effective. The aim was to establish the optimum concentration which would be appropriate to use in a larger randomized clinical trial. METHODS: A masked randomized clinical trial of three concentrations of chlorhexidine compared with natamycin 5% was carried out in consecutive patients with established corneal ulcers shown by microscopy to contain fungal hyphae and later proven to be culture positive. Topical treatments were applied 1/2-hourly to 2-hourly for up to 5 days, with reduced frequency thereafter, and all patients were re-assessed at 21 days. RESULTS: Of 60 patients entered in the trial, 2 were lost to follow-up, and 12 were classified as 'severe' with little prospect of recovery. At 5 days the response was related to the concentration of chlorhexidine, with 0.2% giving the best results. Compared with the response to natamycin as the referent, the relative efficacy was 1.17 with chlorhexidine 0.05%, 1.43 with 0.1%, and 2.00 with 0.2%. The superiority of 0.2% chlorhexidine over natamycin was statistically significant (relative efficacy 2.20, p = 0.043) in patients not having had prior antifungal treatment. CONCLUSIONS: This preliminary study justifies further trials of chlorhexidine as a primary treatment for fungal corneal ulcers in circumstances where specific antifungal agents are not available.
Administration, Topical↗
Specificity of G alpha q and G alpha 11 gene expression in platelets and erythrocytes. Expressions of cellular differentiation and species differences.
G alpha q and G alpha 11, members of the Gq family of G-proteins, transduce signals from receptors to the beta isoenzymes of phosphatidyl-inositol-specific phospholipase C (PI-PLC). The receptor specificity of these alpha subunits is unknown. G alpha q and G alpha 11 are ubiquitously expressed in tissues; however, there have been conflicting reports of the presence or absence of G alpha 11 protein in haematopoietic cells. Platelet thromboxane A2/prostaglandin H2 (TXA2/PGH2) receptors activate PI-PLC via G alpha q, but the role of G alpha 11 is uncertain. To define their roles in platelet activation we studied G alpha q and G alpha 11 gene expression by immunotransfer blotting and by reverse transcription of mRNA followed by PCR (RT-PCR) and direct sequencing. An antiserum specific for mouse G alpha 11 failed to identify G alpha 11 in dog or human platelets or in dog liver, a tissue known to contain G alpha 11. RT-PCR performed with gene-specific primers demonstrated G alpha q mRNA, but not G alpha 11 mRNA, in normal human and mouse platelets and in thromboxane-sensitive and thromboxane-insensitive dog platelets. Studies of mouse and dog liver and human retina confirmed that the cDNA, primers and probes used could amplify and recognize G alpha 11 in other tissues. However, species-specific oligonucleotide primers and probes were essential to demonstrate G alpha 11, but not G alpha q, mRNA. Compared with mouse cDNA, dog and human G alpha 11 cDNA had twice as many nucleotide substitutions (approx. 12% compared with approx. 6%) as G alpha q, G alpha q mRNA was also found in mature erythrocytes but G alpha 11 mRNA was not identified, whereas both G alpha q and G alpha 11 mRNAs were found in bone marrow stem cells. Therefore G alpha 11 gene expression in haematopoietic cells is linked with cellular differentiation. The lack of G alpha 11 indicates that signal transduction from platelet TXA2/PGH2 receptors to PI-PLC occurs via G alpha q, and that G alpha 11 deficiency is not responsible for defective activation of PI-PLC in thromboxane-insensitive dog platelets. Despite the high degree of similarity that exists between G alpha q and G alpha 11, significantly greater species-specific variation in nucleotide sequence is present in G alpha 11 than in G alpha q. Cellular specificity and species specificity are important characteristics of these Gq family G-proteins.
Amino Acid Sequence↗
Glaucoma in Mongolia. A population-based survey in Hövsgöl province, northern Mongolia.
OBJECTIVES: To determine the prevalence of glaucoma and suspect glaucoma, and to classify the cases detected according to mechanism. DESIGN: A population-based prevalence study. SETTING: Rural and urban locations in Hövsgöl province, northern Mongolia. PARTICIPANTS: Nine hundred forty-two (94.2%) of 1000 individuals 40 years of age and older were examined. MAIN OUTCOME MEASURE: Primary angle-closure glaucoma was diagnosed in subjects with previous acute or intermittent symptoms of angle closure and in individuals with an occludable angle and an intraocular pressure greater than 19 mm Hg or a glaucomatous visual field. RESULTS: The prevalence of manifest primary angle-closure glaucoma was 1.4% (14 subjects). The prevalence of gonioscopically occludable angles was 6.4% (64 subjects, including those with glaucoma). Primary open-angle glaucoma was diagnosed in 5 subjects (prevalence, 0.5%). As all these subjects were older than 60 years, the prevalence became 2.1% for this age group. Three cases (prevalence, 0.3%) of secondary open-angle glaucoma were detected. No cases of secondary angle-closure glaucoma were diagnosed. The prevalence of blindness was 1.2% (12 subjects), and primary glaucoma accounted for one third of these cases (4 subjects). CONCLUSIONS: We confirmed glaucoma as a major public health problem in northern Mongolia. Primary angle-closure glaucoma is more prevalent than primary open-angle glaucoma, supporting clinic-based data from other east Asian countries. Among the subjects examined, 97 (9.7%) had either manifest, latent, or suspect glaucoma. Neighboring populations may be similarly affected owing to a shared genetic heritage.
Adult↗
Perceived overqualification and psychological well-being.
The relationship between perceived overqualification and psychological well-being was explored within the framework of stress-illness models, using multiple regression analysis. Data were collected from 179 male and 109 female members of a local midwestern chapter of the American Postal Workers Union. As expected, there was a significant, positive relationship between perceived overqualification and psychological well-being: The greater the perceived overqualification, the greater the psychological distress. The interaction between perceived overqualification and gender was not significant.
Adult↗
A statewide, population-based time-series analysis of the outcome of ruptured abdominal aortic aneurysm.
OBJECTIVES: The purpose of this study was to perform the first statewide, population-based, time-series analysis of the frequency of ruptured abdominal aortic aneurysm (RAAA), to determine the outcomes of RAAA, and to assess the association of patient, physician, and hospital factors with survival after RAAA. The hypotheses of the study were as follows: 1) the rate of RAAA would increase over time and 2) patient, surgeon, and hospital factors would be associated with survival. BACKGROUND: Ruptured abdominal aortic aneurysm is a life-threatening emergency that presents the surgeon with a technically demanding challenge that must be met and surmounted in a short time if the patient is to survive. METHODS: Data were obtained from the following four separate data sources: 1) the North Carolina Hospital Discharge database, 2) the North Carolina American Hospital Association database, 3) the North Carolina State Medical Examiner's database, and 4) the Area Resource File. All patients with the diagnosis of an abdominal aortic aneurysm (AAA) were selected for initial assessment. Patients were grouped into those with and those without rupture of the abdominal aneurysm. RESULTS: During the 6 years of the study, 14,138 patients were admitted with a diagnosis of AAA. Of these, 1480 (10%) had an RAAA. The yearly number of patients with elective AAAs increased 33% from 1889 in 1988 to 2518 in 1993. The yearly number of RAAAs increased 27% from 203 to 258. The mortality rate for AAA was 5%, as compared with 54% in RAAA patients. The patient's age was found to be the most powerful predictor of survival. Univariate logistic regression analyses demonstrated an association of the surgeon's experience with RAAA and patient survival after RAAA. Analysis of the survival rates of board-certified and nonboard-certified surgeons demonstrated that patients with RAAAs who were treated by board-certified surgeons had significantly better survival. When the survival was compared in small (less than 100 beds) and large (more than 100 beds) hospitals, survival was significantly better in the larger hospitals. CONCLUSIONS: Ruptured abdominal aortic aneurysm remains a highly lethal lesion, even in the best of hands. Despite the many improvements in the care of seriously ill patients, there was no significant improvement in the survival of RAAA during this study. This suggests that early diagnosis is the best hope of survival in these patients. The study demonstrated that survival after RAAA was related most strongly to patient age at the time of the RAAA. The physician's and the hospital's experience with RAAA, the physician's background as measured by board certification, and the type of hospital at which the operation was performed (small vs. large) also may be associated with survival. These findings may have important implications for the regionalization of care and the education and credentialling of physicians. Given the lack of recent progress of improving the outcome of RAAA, aggressive efforts to treat patients before rupture are appropriate.
Age Distribution↗